Sheath assembly for insertion of a cord-shaped element, particularly a catheter, into the body of a patient

ABSTRACT

Sheath assembly for the insertion of a cord-shaped element ( 32, 105 ), comprising an introducer sheath ( 101 ) and an auxiliary sheath ( 104 ) for insertion into the introducer sheath ( 101 ) together with the cord-shaped element ( 32, 105 ), with first fastening means ( 106 ) for detachably fastening the auxiliary sheath to the introducer sheath, and with second fastening means ( 107 ) for detachably fastening the cord-shaped element to the auxiliary sheath, wherein the introducer sheath ( 101 ) has a first sheath housing ( 13, 114 ) and a distal tubular section ( 11, 41  a) that terminates in the first sheath housing, and a first flushing device ( 108 ), wherein the auxiliary sheath ( 104 ) has a second sheath inner chamber ( 111 ), a distal, tubular part ( 112 ) and a second flushing device ( 109 ).

The invention relates to the field of mechanics and can be used withparticular advantage in the field of medical technology. Moreparticularly, it relates to a sheath assembly which enables acord-shaped element, particularly a catheter, to be inserted at leastpartially into the body of a patient.

It is known, in principle, to use an introducer sheath for the purposeof inserting a catheter into the body of a patient, for example, into ablood vessel, with the proximal end of said sheath protruding from thebody of the patient while the distal end remains inside the body of thepatient. Such introducer sheaths can be designed as integrated, forexample, however they can also be simply inserted under sterileconditions through the skin or through an orifice in the body of thepatient. Such a sheath is advantageous, for example, when a catheterwill be inserted into a blood vessel of a patient and will also beremoved therefrom. One particular application of such catheters involvescatheters having functional elements, for example, hollow catheters atthe end of which a blood pump is located, which will be transportedthrough a blood vessel up to a chamber of the heart or up to a largerblood vessel, where it will optionally be expanded. Suitable blood pumpswhich can be expanded and later re-compressed are known in multipleforms in the literature.

However, other devices can also be attached to the catheter asfunctional elements, for example, surgical cutting devices for removingdeposits in blood vessels or the like.

Particularly for the insertion of catheter pumps, it has already beenproposed to use an auxiliary sheath in addition to an introducer sheath,with the catheter having the compressed pump being inserted into theauxiliary sheath, wherein the auxiliary sheath temporarily holds the endportion of the catheter and the compressed pump and is inserted togetherwith the pump into the introducer sheath.

It is known to provide a flushing device inside a sheath, in the sheathinner chamber where an object will be inserted into the sheath, whichdevice can be used to flush the element to be inserted and/or the sheathintake prior to insertion or during insertion in order to preventbacteria and/or air from penetrating into the body of the patient. It isalso known to provide sealing devices on sheaths of this type, in order,on one hand, to prevent blood or other bodily fluids from escaping fromthe sheath prior to insertion of an element through the sheath, and onthe other hand, to seal the opening through which an element will beinserted into the sheath from the area outside said opening to thegreatest possible extent during insertion of said element into thesheath.

In light of the described prior art, the object of the present inventionis to devise a sheath assembly comprising an introducer sheath and anauxiliary sheath which will permit the insertion of a cord-shapedelement, particularly a catheter, by means of the auxiliary sheath intothe introducer sheath in the most comfortable manner possible, therebygenerally preventing, to the greatest extent possible, bacteria or otherundesirable objects and substances from penetrating into the body of thepatient. The sheath assembly is also to be protected to the greatestpossible extent against the escape of bodily fluids. Furthermore, traumato the patient is to be minimized to the greatest possible extent, towhich end the outer diameter of the introducer sheath is to exceed theouter diameter of the (optionally compressed) functional element and/orthe catheter as little as possible.

The problem is solved by features specified in this application.

The solution involves a sheath assembly for the insertion of acord-shaped element, particularly a catheter, into the body of apatient, comprising an introducer sheath, the distal end of which isprovided for insertion into the body of a patient and the proximal endof which protrudes from the body of the patient when the distal end isinserted into the body of the patient, and comprising an auxiliarysheath for insertion into the introducer sheath together with thecord-shaped element/catheter, with first fastening means forparticularly detachably fastening the auxiliary sheath to the introducersheath, and with second fastening means for particularly detachablyfastening the cord-shaped element to the auxiliary sheath, wherein theintroducer sheath has a first sheath inner chamber having a firstreceiving channel for a cord-shaped element and a first flushing devicefor flushing the sheath inner chamber, wherein the auxiliary sheath hasa second sheath inner chamber having a second receiving channel for acord-shaped element and a second flushing device for the second sheathinner chamber. For example, the solution involves a sheath assembly forthe insertion of a cord-shaped element, particularly a catheter, intothe body of a patient, comprising an introducer sheath, the distal endof which is provided for insertion into the body of a patient, and theproximal end of which protrudes from the body of the patient when thedistal end is inserted into the body of the patient, and comprising anauxiliary sheath for insertion into the introducer sheath together withthe cord-shaped element/catheter, with first fastening means forparticularly detachably fastening the auxiliary sheath to the introducersheath, and with second fastening means for particularly detachablyfastening the cord-shaped element to the auxiliary sheath, wherein theintroducer sheath has a first sheath housing, and located therein, afirst sheath inner chamber having a first receiving channel for acord-shaped element and a distal, tubular section which terminates inthe first sheath housing, and a first flushing device for flushing thesheath inner chamber, wherein the auxiliary sheath has a second sheathinner chamber having a second receiving channel for a cord-shapedelement, a distal, tubular part and a second flushing device for thesecond sheath inner chamber, and wherein the first sheath housing hasmeans for positioning the distal end of the tubular part of theauxiliary sheath in the first sheath housing and proximally in front ofthe proximal end of the tubular section.

The sheath assembly according to the invention ensures that theauxiliary sheath can be permanently and reliably attached to theintroducer sheath, and that both the introducer sheath and the auxiliarysheath can thereby be flushed and thus kept clean and sterile. In theinterior of the introducer sheath, the inner chamber between theauxiliary sheath and the introducer sheath and/or between the distalpart of the auxiliary sheath and the introducer sheath can be flushedand thereby kept sterile. Inside the auxiliary sheath, the region insidethe auxiliary sheath along with the cord-shaped element, particularlythe catheter, that is located in or protrudes into said region can beflushed and thereby kept sterile. This results in an overall assemblywhich is permanently held together mechanically, at least until theconnection between introducer sheath and auxiliary sheath isdeliberately released, and which permits flushing in a simple manner atthe transition from the introducer sheath to the auxiliary sheath and atthe transition from the auxiliary sheath to the cord-shaped elementlocated therein. In this manner, it can be ensured that, on one hand,the number of microbes and/or other contaminants that penetrate from theexterior into the introducer sheath is minimized, while at the same timeblood is prevented from escaping from the introducer sheath and theauxiliary sheath.

The means for positioning the tubular part of the auxiliary sheathinside the introducer sheath can advantageously comprise a cylindricalchannel inside the introducer sheath, the diameter of which correspondsto the diameter of the tubular part of the auxiliary sheath or does notdeviate substantially from this diameter, that is, by no more than 30%and particularly by no more than 15%. An annular land, projectingradially inward, in the form of a narrowing of a channel for the tubularpart of the auxiliary sheath, which land forms an axial stop or an axialstop of a different configuration, can also be provided. A correspondingland can leave a round opening, the diameter of which corresponds to theinner diameter of the tubular part of the auxiliary sheath or does notdeviate substantially from this diameter, that is, by no more than 30%and particularly by no more than 15%. Such an axial stop can also beoffset, and can therefore be located within the tubular section of theintroducer sheath. It is possible to design the system such that theauxiliary sheath is inserted into the tubular section of the introducersheath only far enough that the auxiliary sheath itself remains proximalto the opening in the patient's skin. This allows the diameter of theintroducer sheath to exceed the diameter of the compressed functionalelement of the catheter only minimally, thereby minimizing the traumaand risk of bleeding to the patient.

In another further development, the inner diameter of the tubularsection of the auxiliary sheath can also be greater than the innerdiameter of the tubular section of the introducer sheath, as a result ofwhich the functional element is compressed in two stages. First, in afirst step, as the catheter is being advanced into the auxiliary sheath,the functional element is compressed to the inner diameter of theauxiliary sheath. As it is being transferred to the introducer sheath,the diameter of the functional element is then further compressed untilit corresponds to the inner diameter of the introducer sheath. Thistwo-stage compression ensures that the forces for compressing thefunctional element do not exceed a critical value at which theconnection of the functional element to the catheter would be destroyed,for example. The same applies similarly to sheaths having a non-circularcross-section, for example, sheaths having an oval or ellipticalcross-section.

One advantageous embodiment of the invention provides that the auxiliarysheath has a tubular distal part and a proximal sheath housing, and thatonly the tubular part is connected, particularly detachably, to theintroducer sheath.

In this case, the tubular part of the auxiliary sheath can be clamped ina simple manner, and therefore detachably fastened, inside theintroducer sheath, wherein an advantageous assembly is configured suchthat the difference in concentricity of the tubular sections of thesheaths in relation to one another in the clamping region is no greaterthan 30% of the larger inner sheath diameter, and particularlyadvantageously is no greater than the difference between the diametersof the sheaths. This helps to prevent the cord-shaped element/catheterfrom having to surmount edges created by the difference in diameterswhich might damage the cord-shaped element/catheter during the transferthereof from the auxiliary sheath into the introducer sheath. Inside theauxiliary sheath, the exterior of the tubular part of the auxiliarysheath can be kept sterile by means of a flushing device, and theinterior of the introducer sheath can be kept sterile by means of aflushing device. A cord-shaped element/catheter, for example with acompressed blood pump, can be contained inside the tubular part of theauxiliary sheath during insertion of this part into the introducersheath. Once the tubular part of the auxiliary sheath has been insertedinto the introducer sheath, the blood pump can be transferred from theauxiliary sheath into the introducer sheath, for example, into a tubularpart of the introducer sheath. In this process, the sterility of thesurrounding area is simultaneously ensured during the transfer processby flushing the interior of the introducer sheath.

A sterile tube, in which the tubular part of the auxiliary sheath can bearranged, can be attached, fluid-tight, to the end face of theintroducer sheath. The sterile tube can terminate in a fluid-tightmanner at the auxiliary sheath, particularly the housing thereof. Thesterile tube can be axially compressible, to allow the auxiliary sheath,particularly the tubular part thereof, to be pushed into the introducersheath and deposited there once the cord-shaped element has beeninserted into the introducer sheath. The sterile tube can be embodied,for example, as a corrugated tube.

A further advantageous embodiment of the invention provides that theauxiliary sheath has a tubular, distal part and a sheath housing, andthat the sheath housing of the auxiliary sheath is connected,particularly detachably, to the introducer sheath, particularly to asheath housing of the introducer sheath.

If the sheath housing of the auxiliary sheath is fixedly connected tothe sheath housing of the introducer sheath, this will result in a solidand non-deformable unit as a whole, which can be handled particularlyeasily on the body of the patient. It is then also particularly easy toinsert the cord-shaped element through the auxiliary sheath into theintroducer sheath. Once the auxiliary sheath has been connected to theintroducer sheath, the sheath assembly acts as a single, multistagesheath.

The invention can further be advantageously embodied in that theauxiliary sheath is connected to the introducer sheath in the form of adetachable, force-sheathing or friction-sheathing clamp connection, adouble-cone connection, a screw connection, a bayonet connection, apress-fit connection or some other detachable mated connection.Detachable connections of this type can be easily produced and thenreleased again under surgical conditions. Due to the simple mechanicalfunctioning, no chemically active joining agents are required, andtherefore, there is no risk of contamination when used in live patients.The relevant connection can be released just as easily as it isproduced.

Individual examples of corresponding detachable connections will bespecified in greater detail further below in connection with theembodiment examples.

The invention can further be advantageously implemented in that thesecond flushing device is connected to the first flushing device. Inthis case, it is provided, in particular, that fluid can be exchangedbetween the first and second flushing devices, so that the same fluid isused for both flushing devices. This decreases cost and increases thecertainty of sterility. The same pump may also be used for the first andsecond flushing devices for moving the flushing fluid, for example.

In this case, it can advantageously be provided that the inner chamberof the sheath housing of the auxiliary sheath is connected directly tothe first flushing device by means of an auxiliary flushing channel. Inone implementation, for example, the auxiliary flushing channel canextend through a line in the form of a hose or tube, which is attachedto the outer periphery of the housing of the auxiliary sheath. In thiscase, the flushing device of the auxiliary sheath and the flushingdevice of the introducer sheath can have the same design, in which onlythe two flushing channels are connected to one another.

However, it can also be advantageously provided that the auxiliaryflushing channel extends directly from the sheath housing of theintroducer sheath into the interior of the tubular part of the auxiliarysheath, particularly through openings in the outer surface of thetubular part of the auxiliary sheath. Therefore, within the innerchamber of the sheath housing of the introducer sheath, the interior ofthe auxiliary sheath, particularly the interior of a tubular part of theauxiliary sheath, can be flushed along with the exterior region of theauxiliary sheath located inside the introducer sheath in that thetubular part of the auxiliary sheath has openings in the outer surfacethereof, through which the flushing fluid can penetrate. The flushingfluid can then advantageously flow in an axial direction along thetubular part of the auxiliary sheath, allowing the auxiliary sheath tobe flushed as a whole unit.

In this case, the flushing fluid is able to travel from the introducersheath into the sheath housing of the auxiliary sheath, and is therebyable to move, in principle, between the auxiliary sheath and thecord-shaped element/catheter located therein, so that thecatheter/cord-shaped element as such is also kept sterile. Saidcatheter/cord-shaped element will be inserted into the body of thepatient, and therefore, the cord-shaped body itself/the catheter must bekept sterile.

A further advantageous embodiment of the invention provides that, in thecase of a direct connection between the sheath housing of the auxiliarysheath and the sheath housing of the introducer sheath, the auxiliaryflushing channel extends within the connecting region, particularlythrough a region of the wall of the sheath housing of the auxiliarysheath that is located within the introducer sheath, or also through apart of the wall of the housing of the introducer sheath that isencompassed by part of the auxiliary sheath. In this embodiment, afixed, channel-like connection between the inner chamber of theintroducer sheath and the inner chamber of the housing of the auxiliarysheath is produced, which allows the flushing fluid to be reliablytransferred between the inner chambers of the housings of the twosheaths. In addition, at least one opening in the outer surface of thehousing of the auxiliary sheath can be provided, which can serve eitherfor discharging the flushing fluid or for venting.

Alternatively or additionally, a hypodermic needle can also be attachedto the distal end of the auxiliary sheath, for example, penetratingthrough a rubber gasket, for example, a dome gasket or plate gasket, inthe introducer sheath as the auxiliary sheath is being inserted into theintroducer sheath, and projecting into the interior of the flushingchamber of the introducer sheath. As a result of this, a communicationchannel is produced by the hollow chamber of the needle between theinner chamber of the housing of the introducer sheath and the housing ofthe auxiliary sheath.

One advantageous embodiment of the invention further provides that theintroducer sheath and the auxiliary sheath abut one another in anannular region as connecting partners, and that in the annular region,an annular or arcuate circumferential groove, extending in thecircumferential direction, is provided in at least one of the twoconnecting partners, and that in both the sheath housing of theintroducer sheath and the sheath housing of the auxiliary sheath, achannel-like recess is provided, which connects the interior of therespective sheath to the circumferential groove in the connected state.In this case, either a housing part of the introducer sheath canencompass a housing part of the auxiliary sheath in the connectionregion, or conversely, a housing part of the auxiliary sheath canencompass a housing part of the introducer sheath in said region.

Because the channel-like recesses in the housing, particularly in thehousing wall, of the introducer sheath and in the housing, particularlythe housing wall, of the auxiliary sheath are connected to one anotherby means of an annular or arcuate channel, even a rotation of theauxiliary sheath relative to the introducer sheath will not prevent theestablishment of the connection between the channel-like recesses. Thisresults in high reliability in establishing the connection between theflushing chambers of the introducer sheath and the auxiliary sheath assoon as the two housings are connected to one another, regardless of anyrotation of the parts relative to one another. In this connection, thechannel-like recesses and/or the circumferential channel can beconfigured such that at least the channel provided in the housing of theintroducer sheath, and particularly both channels, are closed by asliding element as soon as the two sheath housings are separated fromone another.

In what follows, the invention will be specified in reference to anembodiment example illustrated in a set of drawings, and will bedescribed in greater detail below. First, possible methods for securingan auxiliary sheath in an introducer sheath or a catheter in anauxiliary sheath will be described, after which the combination offlushing devices and the fastening of the two sheaths to one anotherwill be specified in greater detail.

FIG. 1 a schematic overview of a cardiovascular system with an insertedsheath;

FIG. 2 a detailed view of a section of FIG. 1;

FIG. 3 an embodiment of the invention having a first sheath (introducersheath) and a second sheath (auxiliary sheath);

FIG. 4 an embodiment of a pump;

FIG. 5 a second sheath (auxiliary sheath) with a pump extractedtherefrom;

FIGS. 6 and 7 the retraction of a pump into a second sheath (auxiliarysheath);

FIGS. 8 and 9 the transfer of a pump from a second sheath to a firstsheath (introducer sheath);

FIG. 10 a longitudinal section of a sheath housing having a tubularsection;

FIG. 11 a longitudinal section of part of a sheath housing having acutting device;

FIG. 12 a longitudinal section of a sheath housing having a clampingdevice for the tubular section and an additional clamping device;

FIG. 13 a a longitudinal section of an alternative clamping ring havinga conical clamping pad;

FIG. 13 b a longitudinal section of a clamp connection having flutes andbeads, each on the outer surface;

FIG. 13 c a longitudinal section having a clamp connection in the formof a threaded connection;

FIG. 13 d a longitudinal section having a clamp connection in the formof a conical connection with a bayonet sheath;

FIG. 13 e a view of the cone of FIG. 13 d rotated 90°;

FIG. 13 f a longitudinal section of a luer cone connection having athreaded connection;

FIG. 13 g a longitudinal section of a clamp connection having a springclip that can be guided in the sheath housing, displaced transversallyand expanded radially;

FIG. 13 h a possible embodiment of the element to be clamped in theregion of the clamping point;

FIG. 13 i a spring clip of FIG. 13 g from a side view, rotated 90° inrelation to FIG. 13 g;

FIG. 14 a longitudinal section of a sheath housing having a clampingdevice for a proximally inserted cord-shaped element;

FIG. 15 an introducer sheath and an auxiliary sheath coupled thereto,wherein the flushing devices of the two sheaths are coupled;

FIG. 16 an introducer sheath and an auxiliary sheath coupled thereto,wherein a connection to the interior of the auxiliary sheath is locatedin the interior of the introducer sheath;

FIG. 17 a sheath assembly, in which the sheath housings of auxiliarysheath and introducer sheath are securely connected; and

FIG. 18 an introducer sheath with an auxiliary sheath, which can bereceived in a sterile tube.

FIG. 19 a an axial sectional view of an introducer sheath with anauxiliary sheath and a cord-shaped element/catheter inside the auxiliarysheath, wherein the auxiliary sheath extends inside the introducersheath;

FIG. 19 b an axial sectional view of an auxiliary sheath with acord-shaped element/catheter inside the auxiliary sheath;

FIG. 19 c an axial sectional view of an introducer sheath with acord-shaped element/catheter inside the introducer sheath.

FIG. 1 shows a schematic illustration of a human cardiovascular system1. In the region of the groin is one of the femoral arteries 2, which isconnected via a major artery to the aortic arch 3, and then leads to thecardiac chamber 4. Using the Seldinger technique, for example, first anintroducer sheath 10 is inserted into the femoral artery 2. In thisprocess, first the femoral artery or some other blood vessel ispunctured using a steel cannula with a cutting tip, for example. A guidewire 12 is then pushed through the steel cannula inserted through thepuncture opening, and is inserted retrograde via the aortic arch 3 intothe left ventricle 4. Once the puncturing cannula has been removed, thefirst sheath 10, embodied as the introducer sheath, which comprises atubular section 11 and optionally a dilator, not shown here, is threadedonto the guide wire and is inserted through the puncture site into thecardiovascular system, wherein the sheath is inserted a short distanceinto the lumen of the cardiovascular system or also up to the site wherean element to be inserted will be deployed. A fluid pump is theninserted through the introducer sheath 10 into the cardiovascularsystem.

The tubular section 11 of the first sheath 10 is inserted into theartery such that the proximal end of the first sheath 10 lies outside ofthe femoral artery and protrudes from the body of the patient, and cantherefore be used for inserting a blood pump, for example. It istherefore possible to thread the pump onto the guide wire 12 to allowthe pump to be guided with the help of the guide wire up to the leftventricle.

It is also possible to guide the tubular part/section 11 of the firstsheath/introducer sheath 10, guided by means of the guide wire, up tothe left ventricle, and to then remove the guide wire 12 from the firstsheath. Any pump unit can then be guided through the first sheath lumenup to the vicinity of or into the left ventricle 4.

Above, the method is described only in reference to the insertion of apump into the left ventricle to support cardiac function. However, itwill be readily clear to a person skilled in the art that the pump orsome other functional element can also be positioned and inserted intoother locations in the cardiovascular system of the body.

It goes without saying that, rather than a blood pump/cardiac supportpump, some other functional element, particularly a compressible andexpandable element, can be inserted using a catheter via the sheath.

FIG. 2 shows the region of FIG. 1 in which the first sheath 10 is guidedfrom the exterior through the tissue of the body into the lumen L_(G) ofthe femoral artery 2. The first sheath in this case comprises a tubularsection 11, which is connected proximally to a sheath housing 13. Thetubular section 11 defines a lumen L₁, which has an inner diameter d₁₁.Said lumen widens in a trumpet shape toward the proximal end of thetubular section 11, in the region 14.

The sheath housing 13 contains a hemostatic valve that is known in theprior art. Said valve prevents fluid that is held inside the lumen L_(G)from escaping through the lumen L₁ to the outside.

In the illustration of FIG. 3, the first sheath 10 of FIG. 2 is coupledto a second sheath 20. Only a tubular section 21 of the second sheath 20(auxiliary sheath) is shown, which defines a lumen L₂ having an innerdiameter d₂₁. The distal end of the second sheath 20 has an outerdiameter that is such that said end can be inserted into the sheathhousing 13. However, the inner diameter d₂₁ is greater than innerdiameter d₁₁.

A pump that is located inside the lumen L₂ and is not shown here canthen be transferred from the second sheath lumen L₂ into the firstsheath lumen L₁ by applying pressure. The pump is then transportedthrough the first sheath lumen L₁ up to the site in the cardiovascularsystem where the pump will be deployed. in this step, the pump caneither be guided on a guide wire or inserted without a guide wirethrough the first sheath lumen. To protect the pump and the vascularwalls as well as the shaft catheter, the first sheath can be fed forwarddistally up to the site of deployment of the pump before the pump ispushed out.

One possible embodiment of a pump 30 will be specified in greater detailin reference to FIG. 4. The pump 30 comprises a distal pump unit 31 anda shaft catheter 32 that is attached to the proximal end of the distalpump unit 31. The shaft catheter 32 has at its proximal end, which isnot shown here, a coupling for coupling the shaft catheter 32 to a driveunit. The drive unit can be located outside of the patient's body androtates a flexible shaft, which extends inside the shaft catheter 32,which in turn drives the distal pump unit 31. However, the presentinvention is also suitable for inserting pumps that are differentlyactuated (by means of an electric motor situated on the pump or by meansof a pneumatic turbine arranged in the pump).

The distal pump unit comprises a pump housing 33, which is produced fromintersecting nitinol braces. Parts of the nitinol housing are providedwith a coating 34, which extends distally and proximally to a rotor 35arranged inside the housing 33. The rotor is connected to the shaft 36which extends through the shaft catheter 32 and is thereby placed inrotation. The housing and the rotor are compressible, i.e., the pump isa self-decompressing pump. The pump is expanded once the distal pumpunit has been pushed out of the distal end of a sheath. To compress thepump in preparation for implantation, the distal pump unit is retractedinto the distal end of a sheath lumen of a second sheath (auxiliarysheath). This sheath lumen has an inner diameter which can be greaterthan the outer diameter of the shaft catheter.

The rotor can be displaceable in the axial direction in relation to thepump housing, particularly by means of axial displacement of the driveshaft. Conversely, the rotor can also be fixed in the axial direction inrelation to the pump housing.

The pump optionally has a discharge tube 37, which defines a flowchannel, located proximally to the rotor 35, for the pumped fluid.Located at the proximal end of the discharge tube 37 are outletopenings, which are not described in greater detail.

Of course, the pump can also be switched from pumping operation tosuction operation, so that the pump no longer conducts fluid from thedistal end to the proximal end, but vice versa.

A more detailed description of a further suitable pump may be found, forexample, in document EP 2 047 872 A1.

The functioning of the system will now be specified in greater detail inreference to FIGS. 5 to 9.

FIG. 5 shows a pump 30′, which corresponds substantially to the pump 30according to FIG. 4. For purposes of simplification, details of the pumpare not shown. Only the bulbous housing and the “pigtail” which islocated distally to the bulbous housing and which prevents the cardiacpump from becoming suctioned to the heart wall are shown. The shaftcatheter 32′ extends proximally to the distal pump unit 31′. A secondsheath 20′ is arranged encompassing a region 38′ of the shaft catheter32′, said sheath comprising a lumen L₂, the inner diameter d₂₁ of whichis smaller than the diameter of the distal pump unit 31′ in the expandedstate.

The pump 30′ shown in FIG. 5 is a compressible pump, in other words, thedistal pump unit 31′, which comprises, i.a., the pump housing and therotor disposed therein, is embodied such that it can be compressed,i.e., its diameter can be decreased. Once a quality assurance inspectoror, for example, a doctor has verified the proper functioning of thepump 30′, e.g., by observing the rotational movement of the rotor unitlocated in the distal pump unit 31′ during a test run, the distal pumpunit 31′ is retracted into the lumen L₂ of the second sheath 20′ bypulling the shaft catheter 32′ in the proximal direction. By retractingthe pump into the second sheath 20′, any bending and/or damage to theshaft catheter and/or the shaft that is located therein is avoided. Thepump 30′ and the second sheath 20′ that encompasses the region 38′ ofthe shaft catheter 32′, shown in FIG. 5, form a system 200, which makesit possible to test the functioning of the pump 30′ in good time priorto an operation, and to then compress the pump by pulling the distalpump unit 31′ into the distal end of the second sheath 20′, therebyavoiding damage to the shaft.

Although the system can be implemented both with actively decompressiblepumps and with self-decompressible pumps, it is particularly well suitedfor self-decompressible pumps, i.e., pumps, the distal pump unit ofwhich automatically returns to its original size outside of the sheath.

FIG. 6 shows an intermediate step during retraction of the distal pumpunit 30′ into the lumen of the second sheath 20′. It is clear that thedistal pump unit 30′ is compressible and can be brought to a smallerdiameter, so that the distal pump unit 30′ can be accommodated withinthe lumen of the second sheath 20′.

Also shown in FIG. 6 is a coupling 39′ attached to the shaft catheter32′, which coupling allows the shaft which extends within the shaftcatheter to be coupled to the drive unit. Since the outer diameter ofthe coupling 39′ is frequently greater than the inner diameter of thelumen L₂, in most cases the second sheath 20′ is pushed on in the distaldirection from the proximal end of the shaft catheter 32′ prior to themounting of the coupling 39′, so that the pump is delivered in thesystem 200, i.e., the pump is delivered with the second sheath 20′,which is located proximally to the distal pump unit 31′, and thepre-mounted coupling 39′. FIG. 6 also shows a slight widening of thedistal end of the second sheath 20′. The trumpet-shaped expansion 24′facilitates the insertion of the distal pump unit 31′ into the lumen L₂of the second sheath 20′.

Finally, in FIG. 7, the distal pump unit 31′ as a whole is locatedinside the lumen L₂ of the second sheath 20″. The second sheath 20″ hastwo pre-mounted grip units 22″, which enable a better hold on and/orremoval of the second sheath 20″ as the distal pump unit 31′ is beingretracted into the lumen L₂, and/or a better subsequent tearing away.According to the invention, however, an auxiliary sheath which remainspermanently connected to the introducer sheath or is held therein canalso advantageously be used. Advantageously, if a “pigtail” is provided,this is likewise retracted into the lumen L₂, so that the distal pumpunit 31′ is located inside the lumen L₂, along with components of thepump that are disposed distally in relation to the distal pump unit 31′.

FIG. 8 illustrates how the system 200 of pump 30′ and second sheath 20″is combined in active connection with the first sheath 10 to form asystem 100. First, the second sheath 20″ (auxiliary sheath) is insertedwith its distal end into the sheath housing of the first sheath 10(introducer sheath). As soon as the distal tip of the second sheath 20″reaches the opening of the tubular section of the first sheath 10, thepump is transferred from the second sheath 20′ into the first sheath 10′by pushing the pump in the distal direction, wherein pushing isaccomplished by applying pressure to the shaft catheter 32′. In thisprocess, the diameter of the distal pump unit 31′ is further reduced tothe inner diameter d₁₁ of the lumen L₁.

FIG. 9 shows the subsequent step, in which the distal pump unit 31′ as awhole is located inside the lumen L₁ of the first sheath 10. The factthat the distal pump unit 31′ as a whole is located inside the lumen L₁of the first sheath 10 can be indicated by means of a colored marking50, for example, which is applied to the outside of the shaft catheter32′.

Assuming the second sheath 20″ is embodied as a “peel-away” sheath, itcan then optionally be removed from the shaft catheter 32′ by tearingaway the peel-away sheath from the proximal end to the distal end, andpulling it off of the shaft catheter 32′. The directed tearing away fromthe proximal end to the distal end can be supported by notches A, but isprimarily based on the orientation of the molecular chains of theplastic that is used from the proximal to the distal direction.

Once the sheath has been removed, if applicable, the pump 30′ is furtherguided inside the lumen L₁ of the first sheath 10 up to the desiredlocation.

Optionally, the first sheath can also be pushed forward with the distalsheath opening in the immediate vicinity of the deployment site beforeor after the pump has been inserted. The length of the first sheath issufficient for this purpose.

A reinforcement of the second sheath 20″ is not necessary, particularlywhen the distal pump unit 31′ is retracted into the distal end of thesecond sheath lumen L₂, since the risk that the shaft may break during apulling movement is substantially reduced.

As the pump is being transferred from the second sheath to the firstsheath, as shown in FIGS. 7 to 9, the second sheath can comprise areinforcing structure in the form of an inserted wire, or the tubularsection 21″ of the sheath 20″ can be made not of a flexible plastic butof a rigid plastic or metal.

A further option for stabilizing the pump and the second sheath involvesholding the second sheath 20″ by means of a supporting device 40 in theform of a stable outer sleeve and/or in a receiving channel of theintroducer sheath as the pump 30′ is being pushed forward in a distaldirection, i.e., particularly as the pump 30′ is being transferred fromthe second sheath to the first sheath.

In what follows, another possible variant of a method for inserting apump into a left ventricle of the heart will be described. As apreparatory measure, the pump is first filled with sterile physiologicalsaline solution and is thereby completely vented of air. The auxiliarysheath, which is disposed proximally to the distal pump unit, is thenpushed forward up to a discharge tube, if one is provided. The auxiliarysheath has a diameter of 10 Fr, for example. Once the auxiliary sheathhas been advanced up to the discharge tube, the auxiliary sheath isencompassed by a sleeve-like, supporting device. The distal pump unit isthen retracted, optionally with a slight rotational movement, into theauxiliary sheath by exerting a pulling movement in the proximaldirection on the shaft catheter. The pump is pushed far enough into theauxiliary sheath that any pigtail that exists is likewise concealedinside the auxiliary sheath. These steps allow the proper functioning ofthe pump to be tested prior to a surgical operation, and allow the pumpto be inserted into a sheath only after said testing, without requiringsuch action to be performed under pressure of time. The vascular systemis punctured for insertion of the first sheath only after said testing,for example. To save time, however, this also allows an assistant toprepare the pump while the surgeon performs puncturing in parallel.

Once a 9 Fr introducer sheath has been inserted up to the left ventricleof the heart, for example, a dilator, if one is provided, may optionallybe pulled out of the introducer sheath and removed therefrom.

The pump, which is held inside the auxiliary sheath and which isinitially encompassed by the sleeve, for example, is then pushed intothe sheath housing of the introducer sheath until the tip of theauxiliary sheath strikes a mechanical stop. The pump is then transferredfrom the auxiliary sheath into the tubular section of the introducersheath by applying pressure to the shaft catheter. Once the distal pumpunit as a whole has been transferred into the introducer sheath, as canbe ascertained on the basis of an optical marking on the shaft cathetershaft, for example, the auxiliary sheath can be left inside theintroducer sheath, or optionally, a peel-away sheath can be torn awayand removed from the shaft catheter. The pump is then pushed forwardinside the first sheath (introducer sheath) up to the left ventricle.The first sheath is then pulled back out of the left ventricle up to thestart of the descending aorta.

The positioning of the distal pump unit in the left ventricle can beverified, for example, by x-ray imaging. For this purpose, a markingdetectable by x-ray is located on the pump housing or in the vicinitythereof, for example, on the catheter, or the pump housing itself isdetectable by x-ray. The outlet region of the pump, i.e., the outflowopenings in a delivery tube, should likewise lie in the region of theascending aorta. This can also be verified by means of a marking that isdetectable by x-ray. If a pigtail catheter tip is present, it shouldtouch the tip of the left ventricle.

To remove the pump from the ventricle, the pump is drawn back into theintroducer sheath by applying tractive force to the shaft catheter, andis removed, compressed, from the arterial vascular system. If the firstsheath has already been shortened, the pump can also first be drawn backa short distance into the shaft catheter in order to compress the pump.For this purpose, the shaft catheter can have a retraction funnel, intowhich the pump can be retracted by pulling on the drive shaft. The firstsheath and other remaining components are then removed from thecardiovascular system.

With the invention, it is particularly advantageous to use a long sheathparticularly as the introducer sheath in the implantation andexplantation of the pump. The long sheath serves not only for insertingthe pump into a lumen inside the body, as is customary in the prior art,but also for guiding the pump through the lumen of the sheath into thearea of the deployment site. In this connection, it is advantageous inthe medical field for the sheath to have a length of between 40 and 120cm. The length is determined by the subsequent deployment site of thepump and the physique of the patient.

Once the pump, together with the long sheath, is removed from the lumenof the body, bleeding from the femoral artery is stopped using acompression bandage. Alternatively, the pump can be removed from thelumen of the long sheath. An additional guide wire can then bepositioned through the lumen of the sheath, via which wire a device forclosing the puncture can be guided once the sheath has been removed.This results in improved hemostasis.

FIGS. 10 to 13 specifically show a variant of the first sheath accordingto the invention having one or more clamping devices for securing atubular section 41 in a sheath housing 43.

FIG. 10 also shows a longitudinal section of a sheath housing 43 havingsubstantially the form of a cylindrical sleeve which is closed at leastat the distal end 44, which faces away from the body of the patient, bymeans of a pressure screw 45. The sheath housing 43 has a continuousreceiving channel 46 for a tubular section 41 of the sheath. In thediagram of FIG. 10, the tubular section 41 is indicated by a solid lineup to the flushing chamber 47 of the receiving channel 46, and isindicated by a dashed line proximally thereto. This indicates that thetubular section 41 can be axially displaced in relation to the sheathhousing 43 within the receiving channel 46, or, in other words, that thesheath housing 43 is displaceable on the tubular section 41.

The sheath shown here can be used, for example, as an introducer sheath(first sheath).

To insert a functional element, for example, a pump, into the firstsheath, the tubular section 41 is generally pulled in the distaldirection far enough out of the sheath housing 43 or is positionedduring the production of the first sheath such that it terminatesapproximately at the height of the first stop piece 48, and is thenclamped in place, for example, by actuating the pressure screw 45. Asecond sheath with a retracted pump, as described above, can then bepushed forward up to this point, in order to then move the pump throughfrom the second sheath into the first sheath.

The first clamping device comprises the first pressure screw 45, a firstclamping ring 50 made of an elastomeric material, and the first stoppiece 48 as fastening means. A sliding layer or a rotating seal ring 69can be provided between the clamping ring 50 and the pressure screw 45.

The pressure screw is screw-connected by means of external threading tothe distal end 44 of the sheath housing 43, in the region of the overlaptherewith. Manual rotation of the pressure screw 45 therefore causes thepressure screw to move in the axial direction, resulting in an axialcompression or expansion of the clamping ring 50. In the case of axialcompression, the clamping ring 50 tends to maintain its volume radiallytoward the inside and to expand toward the outside, thereby clamping thetubular section 41, since at its proximal side, the ring meetsresistance against the first stop piece 48.

The tubular section 41 is thereby fixed axially in relation to thesheath housing 43. This fixation can be released simply by releasing thepressure screw 45, so that the tubular section 41 can then be displaceda short distance axially inside the sheath housing 43. To this end, inits relaxed state the clamping ring can have an inner diameter which isequal to or greater than the diameter of the first sheath.

Thus, if the tubular section 41 is first advanced as far as possibleinto the body of the patient in order to allow the pump to be inserted,protected by the sheath, up to the deployment site, for example, to aventricle of the heart, then once the pump has been delivered, thetubular section 41 is withdrawn, and the sheath as a whole projects arelatively great distance out of the body of the patient. The clampingdevice 48, 45, 50 can then be released and the sheath housing 43 can beadvanced closer to the body of the patient on the tubular section 41. Inthis step, the tubular section 41 then extends all the way through thesheath housing 43 and optionally protrudes out of said housing in aproximal direction. Using means which will be described in greaterdetail further below, the tubular section 41 can then be partiallydetached in order to remove the excess length.

To produce a better seal, a so-called combined hemostatic valve,consisting of a dome valve 51 and a valve plate 52, is provided insidethe sheath housing 43. The valve plate closes off the sheath housing 43when neither the tubular section 41 nor a shaft catheter extends throughthe receiving channel 46 at this location, whereas the dome valve 51 isoptimized to produce a tightly fitting seal around a cord-shapedelement, for example, the tubular section or a catheter.

At the proximal end 53 of the sheath housing 43, an additional pressurescrew 54 is provided, which in principle functions in the same manner asthe first pressure screw 45 and which effects, via a clamping pad 55,the compression of a second clamping ring 56 in relation to a secondmechanical stop 57. A catheter or an inserted auxiliary sheath canthereby be clamped into the introducer sheath. As a special feature itshould be mentioned here that the second clamping ring 56 extends in theform of a cone at its distal end, which favors a deformation radiallytoward the inside when axial pressure is exerted by means of thepressure screw 54. The second stop 57 is designed accordingly in anopposing conical shape. However, a clamping ring 56 that is non-conicaland instead has a rectangular or round cross-section can likewise beused at this location.

In FIG. 10, a flushing device 58 is indicated schematically, whichallows the flushing chamber 47, which is the interior of the sheathhousing, to be flushed with a fluid that prevents bacteria from enteringthe patient's body through the first sheath. This flushing isparticularly effective if the tubular section 41 terminates in theflushing chamber 47 or at the distal end thereof, so that the flushingfluid reaches both the exterior and the interior of the tubular section41.

FIG. 11 illustrates by way of example the configuration and mode offunctioning of a cutting device according to the invention.

If no predetermined breaking points are provided, pre-cut or provided insome other way, for example, by a predetermined molecular structure orlocalized weakening of the wall thickness of the tubular section 21,these can be introduced appropriately by means of a cutting deviceduring use of the first sheath. In FIG. 11, a cutting device with blades59, 60 is provided in the region of the flushing chamber 47 of thesheath housing 43, which blades cut said housing in the circumferentialdirection when the sheath housing is rotated in relation to the tubularsection, for example. Cuts may also be made in the axial direction.

For this purpose, the blades 59, 60 can also be arranged such that, whenthe tubular section 41 is moved in an axial direction, as indicated bythe arrow 61, they cut in the longitudinal direction. It is alsopossible to provide blades for cutting in the circumferential directionand one blade for cutting in the longitudinal direction.

FIG. 11 further indicates that the blades 59, 60 can be moved in thedirection radially toward the tubular section 41 by actuating saidblades from the exterior of the sheath housing 43. At said location, aguide extending in the radial direction for one or more blade holders, acorresponding seal, and a spring mounting can be provided, so thatbacteria are prevented from penetrating through this displacement devicefor the blades, and in the non-actuated state, the blades are located ata distance radially from the tubular section 41. Once the first sheathhas been used, pressure can be exerted manually on the blades, and thepart of the tubular section 41 that is no longer needed can be cut off.A stop, not shown here, prevents the cutting depth from exceeding acritical level and thereby damaging a catheter that may be locatedinside the sheath.

The blades shown can also form a cutting device for a second sheath.

FIG. 12 illustrates an advantageous use of the second clamping device atthe proximal end of the sheath housing 43 once the tubular section 41has been shortened, and when a shaft catheter 61 leads out of theproximal end of the tubular section 41 and out of the sheath housing 43,up to a coupling device, not shown, for a driveable shaft of a pump. Theshaft catheter is sealed in the above-mentioned dome seal 51, and theclamping device comprising the elements of the second pressure screw 54,and the second clamping ring 56, which is compressed axially in relationto a second stop 57 by means of the clamping pad 55, expands radiallyinward far enough that it clamps the shaft catheter 61, which has asubstantially smaller outer diameter than the tubular section 41 or asecond sheath, particularly also sealing said catheter. However, saidclamping does not prevent the rotation of the shaft that is rotatabletherein. In this manner, both the tubular section 41 and the shaftcatheter 61 that projects therefrom can be fixed inside the sheathhousing 43.

The second clamping device is likewise suitable for fixing the secondsheath with the second clamping ring 56 during the insertion of a secondsheath into the sheath housing 43 such that said second sheath isadequately fixed in relation to the sheath housing 43 and especiallyalso in relation to the tubular section 41 to allow the shaft catheter61 to be pushed through.

The first and second clamping rings 50, 56 can be made of an elastomer,for example, a rubber or silicone elastomer, and can therefore be fullyflexible, but deformable with an incompressible volume. However, aflexible foam which is partially compressible in terms of volume mayalso be used at this location. In place of a clamping ring 56, aradially displaceable spring clip can also be provided for producing aclamping connection, as is illustrated in FIGS. 13 g, 13 h and 13 i andwill be specified in greater detail further below. A correspondingspring clip can be provided in addition to or in place of a clampingring. The spring clip can be provided in the region of the dashed lines70 in FIG. 12. However, the spring clip may also advantageously beprovided in the region of the dashed line 70′, since this region liesproximally to the seal 51, and therefore, it is not necessary to exertparticularly high stresses on the seal of the sliding arrangement of thespring clip.

FIGS. 13 a to 13 i show clamping devices and/or securing devices forsheaths, which can be used alone or in combination in an introducersheath and/or an auxiliary sheath.

FIG. 13 a shows a schematic illustration of a type of clamping ring 62,which can be made, for example, of a plastic or a metal, and isparticularly slotted and can therefore be radially compressed. Theslotted clamping ring 62 has a conical external contour, against whichthe conical contour of a clamping pad 63 presses in order to compressthe clamping ring radially as soon as an axial compressive force isexerted on the clamping pad 63 in the direction of the arrow 65, forexample, by means of a pressure screw as described above. The slottedclamping ring 62 is secured axially by means of the stop piece 64.

FIG. 13 b shows an adapter piece 71 inside a sheath housing 43, whichhas a through channel 72, wherein continuous flutes and beads 73 areprovided on the cylindrical outer surface of the through channel 72,which match flutes and beads 74 on a mating adapter piece 75 on theelement 76 to be clamped. The mating adapter piece 75 can be insertedinto the adapter piece 71 and snapped in flexibly, where it is held inplace, advantageously forming a seal. A stop piece 77 prevents theelement 76 from being inserted too far, and allows the snap connectionto be sensed haptically.

FIG. 13 c shows a configuration similar to that of FIG. 13 b, whereinthe adapter piece 71′ and the mating adapter piece 75′ are each equippedwith a thread, rather than concentric, continuous flutes and beads. Themating adapter piece 75′ can be moved into the adapter piece 71′ byrotating it, however it is also conceivable to overcome the threadingand insert said adapter axially. A visible marking 78 is provided on theelement 76 to be clamped, to allow the target position to be identified.However, a shape marking may also be provided, which allows the targetposition to be sensed haptically or acoustically, or a mechanism may beprovided for actuating an electrical contact to emit a signal when thetarget position is reached/left.

FIG. 13 d shows a cone 79 on the element 76 to be clamped, which conefits into a conical recess 80 in the adapter piece 71′ forming a seal.The cone 79 has one or more peripheral pins 81, which are guided ingates 82 on the inner circumferential surface of the recess 80, andserve to form a bayonet-type sheath. Conversely, a pin may also beprovided on the outer cone and a gate on the inner cone. A so-calledluer sheath may be formed while maintaining the corresponding standardin the connection of sealing cone with sheath. Rather than the bayonetsheath, a threaded connection may also be provided in conjunction withthe cone system.

FIG. 13 e shows a rotated side view of the cone 79 with two pins 81.

FIG. 13 f shows a cone system having a cone 79′ and a threaded nut 83that encompasses said cone. The threaded nut 83 can be screwed onto athread of the pipe socket 84, which is connected to the adapter piece85. The adapter piece 85 is securely incorporated into the sheathhousing 43 of an introducer sheath, and has an inner cone. The threadednut 83 can also be embodied as a cap nut which is freely rotatable inrelation to the cone 79′.

FIG. 13 g shows a sheath housing having a radially displaceable springclip, which can be actuated by means of a push button 87. A stop 88 isprovided, which stops the push button 87 in the target position. Inaddition, an optically detectable marking may also be provided on thespring clip. As the spring clip 86 is being moved into the sheathhousing, it enters an opposite guide 89. Prior to this, the spring clipis elastically expanded when it strikes the element 76 to be clamped.Said spring clip has an intake opening 90 for this purpose, as shown inFIG. 13 i. As insertion continues, the holding region 91 comes to restaround the element to be clamped. As is clear from FIG. 13 h, saidelement can have a continuous groove or flute 92, or a collar 93, whichhas such a flute 92. In this variant, the functions of clamping andsealing the element to be clamped are separate.

Conversely to the described functioning method, clamping may also beproduced by advancing the spring clip all the way into the sheathhousing 43 and only then axially inserting the element to be clamped,for example, a catheter or a second sheath. In this case, the conicalguide bevel 94 allows the collar 93 to be inserted along with theelement to be clamped into the spring clip 86, and held in place there.

In principle, the element to be clamped/a second sheath can also be heldin a first sheath by flexible, self-sheathing vanes, fins, or teeth,which, when the element is pulled out of the sheath, sheath said elementor make pulling it out significantly more difficult. Such vanes areillustrated schematically on the left side of FIG. 13 d and areidentified by reference sign 95.

FIG. 14 shows a sheath housing 43′ of an introducer sheath, which has inits interior a receiving channel 46 for a sheath and/or a catheter. Atits distal end 44, the sheath housing 43′ has a tubular section 41 thatis fastened to said end, which can be glued, cast, or otherwisefastened, for example, in an opening of the sheath housing. The tubularsection 41 is inserted into the opening of the sheath housing 43′ up toa mechanical stop 63.

A second sheath 20″′ (auxiliary sheath) is inserted from the proximalend 53 of the sheath housing 43′ into the receiving channel 46 farenough that it terminates distally at the mechanical stop 63. In oneembodiment, the system can also be designed such that the second sheath20″′ terminates directly at the tubular section 41. A functional elementin the form of a pump with a hollow catheter, for example, is retractedinto the second sheath 20″′, no more of which is illustrated.

To transfer the catheter with the pump from the second sheath 20″′ intothe tubular section 41 of the first sheath 43′, 41, the two sheaths arealigned coaxially to one another within the receiving channel 46, andthe second sheath 20″′ is fixed in place by means of a clamping device.The clamping device has a flexible clamping ring 56′, which is embodiedas conical in shape at its distal end and is forced against a mechanicalstop 57′. For this purpose, axial pressure is exerted on the clampingring 56′ by means of a pressure screw 54′ having external threading 64.For this purpose, the pressure screw 54′ is screwed into the opening inthe tubular part of the sheath housing 43′, so that it moves axially inthe direction of the arrow 65.

To reduce the friction between the rotating pressure screw 54′ and theclamping ring 56′, a rotating seal ring 69, for example made of PTFE orsome other plastic having good sliding properties, can advantageously beprovided.

The clamping ring 56′ is made, for example, of an elastomer, and expandsin a radial direction under axial pressure thereby clamping acord-shaped element, which is located in the receiving channel 46. Inthe clamping region, the element to be clamped can have one or morecontinuous beads, lands, grooves or flutes or edges, for example, inorder to improve the clamping effect. A collar may also be provided onthe element for this purpose. The second sheath 20″′ has a wallthickness of between 0.3 and 0.7 mm, and is made of a material that issufficiently stable that under radial pressure, the second sheath can beclamped without the catheter extending therein also being clamped at thesame time. This allows the catheter to be easily pushed out of theproximal end of the second sheath 20″′ into the tubular section 41. Thesecond sheath 20″′ is sealed by a combined plate and dome seal 51, 52 ina flushing chamber 47.

Once the functional element, for example, the pump, has been transferredwith the catheter from the second sheath 20″′ into the tubular section41, the second sheath can be torn away using the manual tabs 67, 68 andremoved. For this purpose, the second sheath can have a weakened area ora notch along its axial direction or a correspondingly predefinedmolecular structure, which allows it to be torn away longitudinally upto the distal end of the second sheath, and allows the second sheath tobe removed accordingly. To tear said sheath away, it may be expedient torelease the clamping device 54′, 56′, 57′.

Once the second sheath has been removed or partially removed, theclamping device 54′, 56′, 57′ can be clamped tightly enough that thecatheter having a smaller diameter is clamped in the receiving space 46as a result of the additional radial compression of the clamping ring56′. The catheter and therefore also a pump to be implanted is therebyfixed at the distal end of the catheter in the axial direction inrelation to the first sheath and therefore in relation to the body ofthe patient.

However, the second sheath (auxiliary sheath) can also be embodied suchthat it can remain in the introducer sheath. In that case, adequatesealing and flushing capability should also be ensured, as will bespecified in greater detail below.

A perceptible stop is implemented by means of formations in the sheathhousing, which are not shown here, for each of the different endpositions of the pressure screw which correspond to the differentdiameters to be clamped, so that the user senses a clearly increasedrotational resistance with actuation of the screw when the respectiveclamping position is reached.

Following an initial phase in which the assembly becomes mechanicallysettled and warms to the body temperature of the patient, the clampingdevice can be released and the catheter readjusted and then refastened.Everywhere in the described construction where two cylindrical elementsare inserted one into the other forming a seal, a conical seal having acone angle of a few degrees can be advantageously used, as is known, inprinciple, in the medical field.

The described embodiment of a sheath allows an implantable heart pump,for example, to be transferred from a second sheath, in which it can bekept ready following an initial inspection, into a first sheath, whichleads into the body of a patient, without problems and with lowcomplexity and high reliability.

FIG. 15 shows an introducer sheath 101 on the right side of said figureand an auxiliary sheath 104 on the left side, the tubular part 112 ofwhich can be inserted into the introducer sheath 101 and clamped inplace there.

The introducer sheath 101, like the auxiliary sheath 104, correspondssubstantially to the sheath illustrated in FIG. 14 and described in thiscontext.

The entire sheath assembly illustrated in FIG. 15 comprises theintroducer sheath and the auxiliary sheath and is suitable for insertinga cord-shaped element/catheter 105 through the auxiliary sheath 104 intothe introducer sheath 101 and through said introducer sheath into thebody of a patient.

The introducer sheath 101 further has at its distal end 102 a tubularpart 41 a, which is fixed forming a seal in the proximal part 103, whichforms a sheath housing 114. The tubular part 112 at the distal end ofthe auxiliary sheath 104 can be inserted into the introducer sheath 101and pushed up to a stop 63 in front of the tubular part of theintroducer sheath. The stop 63 can simultaneously form an axial stop forthe tubular part 112 of the auxiliary sheath and for the proximal end ofthe tubular part 41 a of the introducer sheath, wherein the tubularparts 112, 41 a can have the same inner diameter as the flange-type stop63. The stop 63 is formed in the housing wall of the sheath housing. Theintroducer sheath has first fastening means 106, which can be similar indesign, for example, to the second fastening means 107 of the auxiliarysheath 104 and which has been described in greater detail in referenceto FIG. 14 as a clamping device. In principle, however, the first andsecond fastening means can comprise each of the types of fastening meansshown by way of example in FIGS. 13 a to 13 j.

In order to keep the area of transition between the auxiliary sheath andthe tubular part of the introducer sheath within the inner chamber 110of the housing 114 of the introducer sheath sterile, and to allow saidarea to be flushed for this purpose, a flushing device 108 is providedwith a corresponding flushing tube and an opening provided in the wallof the housing 114. The flushing device is connected to a flushingmedium source 120, which comprises a pump 121 and a reservoir 122, forexample. The auxiliary sheath 104 likewise has a flushing device 109,which comprises a flushing tube and an opening in the wall of thehousing 113. Via this flushing device 109, the housing interior 111 ofthe auxiliary sheath, and thereby the area of transition from thecatheter 105 into the tubular part 112 of the auxiliary sheath, can beflushed and kept sterile.

The first flushing device 108 is connected, for example, to the secondflushing device 109 via the flushing medium source 120. It can therebybe provided that the pump 121 conveys flushing medium into both thefirst flushing device 108 and the second flushing device 109, conveyingsaid medium into the inner chambers of the housings 113, 114.

FIG. 16 shows a variant in which the flushing medium source 120 suppliesflushing medium into the interior 110 of the housing 114 of theintroducer sheath 101 via the first flushing device 108, wherein thetubular part 112 of the auxiliary sheath fixed inside the introducersheath has at least one outer-surface opening 119 in the inner chamber110, for example, an outer-surface perforation consisting of multipleopenings, through which the flushing medium can enter into the tubularpart 112 and can flow through this axially into the housing interior 111of the housing 113. Therefore, the flushing medium can actively travelfrom the flushing medium source 120 through the introducer sheath 101into the auxiliary sheath 104. In such a case, the structural devices ofthe second flushing device 109 can serve to vent the auxiliary sheath,for example, or to discharge the flushing fluid there, in order tocollect this in a collecting tank 123. In this case, the interior of thetubular part 112 of the auxiliary sheath forms a part of the auxiliaryflushing channel 115′ for connecting the two sheaths. In the variantshown in FIG. 15, such an auxiliary flushing channel 115 is provided bythe infeed tubes of flushing devices 108 and 109 and/or the connectionthereof.

The outer-surface openings/recesses 119 in the tubular part 112 of theauxiliary sheath can also be introduced into the part 112 only after thecatheter has been inserted into the body of the patient, for example. Acutting assembly, as illustrated in FIG. 11, for example, may be usedfor this purpose.

Finally, FIG. 17 shows a design in which the sheath housing 114 of theintroducer sheath is securely connected to the sheath housing 113 of theauxiliary sheath 104. The two sheath housings are securely inserted oneinside the other in a cylindrical or slightly conical subregion. Athreaded connection or a bayonet connection may also be provided.

A circumferential groove 116 is provided, which is formed, for example,as in the illustrated version by circumferential grooves in the housing113 of the auxiliary sheath on one side and in the housing 114 of theintroducer sheath on the other side. However, it can also be sufficientto provide a circumferential groove in only one of the housings. Thecircumferential groove or both circumferential grooves are connected viaone channel-like recess 117, 118 each, which extends through the wall ofthe respective housing 114, 113, to a first flushing device 108 and/orto the interior of the respective sheath housing 114, 113. As a result,in the variant shown, both the interior of the housing 114 and theinterior of the housing 113 can be flushed via the first flushing device108. In this case, the second flushing device 109 is used for ventingand for discharging flushing fluid, according to FIG. 16. Conversely,however, flushing of both houses may also be provided by the secondflushing device. Due to the circumferential groove 116 that is provided,it is not necessary to adhere to a precise angular position inconnecting the two sheath housings; rather, it is necessary only for theaxial positions of the two sheath housings 101, 104 to be maintainedrelative to one another. This can be ensured, for example, by a fixedstop on one of the two sheath housings.

In addition, a spring-mounted sliding element on the innercircumferential side of the housing 114 and one such element on theexterior of the housing 113, in each case in the region of thecircumferential groove, can serve to ensure that the correspondingcircumferential grooves and/or channel-like recesses are covered priorto the connection of the two housings. The sliding elements are to bespring-loaded and retractable such that, during joining of the twohousings, the respective circumferential grooves or recesses areuncovered.

In the case of the configuration of FIG. 17, the channel-like recesses117, 118 and/or the circumferential groove 116 form the auxiliaryflushing channel 115″.

The described variants enable the auxiliary sheath 104 to be permanentlyconnected to the introducer sheath 101 and left connected thereto, andallow the two to be flushed together such that in the region of thesheath, bacteria are reliably prevented from penetrating into the bodyof the patient.

FIG. 18 shows an embodiment of the sheath assembly in which a steriletube 130 is attached in a fluid-tight connection to an introducer sheath101. In principle, said tube can be flushed from the introducer sheath101 or from an auxiliary sheath 104′ (shown only partially andschematically in FIG. 18).

The sterile tube 130 is itself embodied as fluid-tight and as acorrugated tube. It can be connected by means of a flange connection oradhesive connection 131, or generally by means of one of the connectiontypes shown in FIGS. 13 a to 13 i, to the housing of the introducersheath 114 and/or to the housing of the auxiliary sheath and/or to acatheter grip, and at least partially encompasses an auxiliary sheath,which is inserted partially into the introducer sheath. The sterile tubecan also be clamped proximally directly to the catheter shaft.

Once a catheter has been inserted into the body of a patient, theauxiliary sheath as a whole can be received inside the sterile tube 130.A proximal end piece 132 has a through channel for the catheter, whichis fed through said channel forming a seal.

Following the insertion process, the sterile tube can be axiallycompressed, and the end piece 132 can be connected to a flange 131, forexample. The auxiliary sheath can also be torn away as a peel-awaysheath, and pulled out of the introducer sheath into the sterile tube,where it will remain. The introducer sheath can then be sealed inrelation to the sterile tube.

FIG. 19 a shows an axial sectional view of a sheath assembly, in which acord-shaped element/catheter 105 extends through the tubular part of anauxiliary sheath 21, which is in turn located inside the tubular sectionof the introducer sheath 41 a. The cord-shaped element/catheter 105,which in the example is shown as a hollow catheter, has an outerdiameter d₁. The tubular part of the auxiliary sheath 21 has an outerdiameter d₂ and an inner diameter, which corresponds to the outerdiameter d₁ of the cord-shaped element/catheter 105. The tubular part ofthe introducer sheath 41 a has an inner diameter which corresponds tothe outer diameter d₂ of the tubular part of the auxiliary sheath, andan outer diameter d_(3a). In general, the wall thicknesses of therespective components cannot be randomly decreased on the basis of thematerial properties.

It is clear that, with a sheath assembly of this type, the outerdiameter d_(3a) of the system as a whole is relatively large due to thearrangement of the tubular sections of auxiliary sheath and introducersheath one around the other, and at the point of passage through theskin of the patient results in a correspondingly high degree of traumaand risk of bleeding.

FIG. 19 b shows an axial sectional view of a sheath assembly in which acord-shaped element/catheter 105 extends through the tubular part of anauxiliary sheath 21, which in turn is located axially proximally to thetubular section of the introducer sheath, which therefore is not shownhere.

It is clear that the outer diameter of the system in this regioncorresponds to the outer diameter d₂ of the tubular part of theauxiliary sheath.

FIG. 19 c shows a further axially sectional view of the sheath assemblyof FIG. 19 b, which is located distally to the sectional view of FIG. 19b in a plane in which the cord-shaped element/catheter 105 extendsthrough the tubular part of the introducer sheath 41 a. A tubular partof the auxiliary sheath is not provided in this plane. Due to theabsence of the auxiliary sheath in this section, the outer diameterd_(3b) of the tubular section of the introducer sheath 41 a can bedesigned as substantially smaller, for example, it can correspond to theouter diameter of the tubular section of the auxiliary sheath 21 or canbe even smaller than this.

It is clear that with such a sheath assembly, the outer diameter d_(3b)of the system as a whole is substantially smaller due to the positioningof the tubular sections of auxiliary sheath and introducer sheath one infront of the other axially, and results in correspondingly less traumaand risk of bleeding at the point of passage through the skin of thepatient.

1. A sheath assembly for insertion of a cord-shaped element (32, 105),particularly a catheter, into the body of a patient, said assemblycomprising an introducer sheath (101), the distal end (102) of which isprovided for insertion into the body of a patient and the proximal end(103) of which protrudes from the body of the patient during insertionof the distal end of said assembly into the body of the patient, andcomprising an auxiliary sheath (104) for insertion into the introducersheath (101) together with the cord-shaped element/catheter (32, 105),with first fastening means (106) especially for detachably fastening theauxiliary sheath to the introducer sheath, and with second fasteningmeans (107) especially for detachably fastening the cord-shaped elementto the auxiliary sheath, wherein the introducer sheath (101) has a firstsheath housing (13, 114) and therein, a first sheath inner chamber (110)having a first receiving channel for a cord-shaped element (32, 105) anda distal tubular section (11, 41 a) that terminates in the first sheathhousing, and a first flushing device (108) for flushing the sheath innerchamber (110), wherein the auxiliary sheath (104) has a second sheathinner chamber (111) having a second receiving channel for a cord-shapedelement (32, 105), a distal, tubular part (112) and a second flushingdevice (109) for the second sheath inner chamber (111), and wherein thefirst sheath housing (13, 114) has means (63) for positioning the distalend of the tubular part (112) of the auxiliary sheath (104) in the firstsheath housing (13, 114), proximally in front of the proximal end of thetubular section (11, 41 a).
 2. The sheath assembly according to claim 1,characterized in that the auxiliary sheath (104) has a tubular, distalpart (112) and a proximal sheath housing (113) and that only the tubularpart (112) is connected, particularly detachably, to the introducersheath (101).
 3. The sheath assembly according to claim 1, characterizedin that the auxiliary sheath (104) has a tubular, distal part (112) anda sheath housing (113), and in that the sheath housing (113) of theauxiliary sheath is connected, particularly detachably, to theintroducer sheath (101), particularly to a sheath housing (114) of theintroducer sheath (101).
 4. The sheath assembly according to any ofclaims 1 to 3, characterized in that the connection between auxiliarysheath (104) and introducer sheath (101) is embodied as a detachableclamp connection with a force-fitting connection or friction connection,as a double-cone connection, a screw connection, a bayonet connection, apress fit connection, or some other detachable mated connection.
 5. Thesheath assembly according to any of claims 1 to 4, characterized in thatthe second flushing device (109) is connected to the first flushingdevice (108) to allow an exchange of flushing fluid.
 6. The sheathassembly according to claim 5, characterized in that the inner chamberof the sheath housing (113) of the auxiliary sheath is connecteddirectly to the first flushing device (108) by means of an auxiliaryflushing channel (115, 115′, 115″).
 7. The sheath assembly according toclaim 6, characterized in that the auxiliary flushing channel (115,115′, 115″) extends through a line in the form of a hose or a tube whichis attached to the outer periphery of the housing of the auxiliarysheath (104).
 8. The sheath assembly according to claim 6, characterizedin that the auxiliary flushing channel (115, 115′, 115″) extendsdirectly from the sheath housing (114) of the introducer sheath (101)into the interior of the tubular part (112) of the auxiliary sheath(14), particularly through outer-surface openings (119) in the tubularpart (112) of the auxiliary sheath.
 9. The sheath assembly according toclaim 6, characterized in that in the case of a direct connectionbetween the sheath housing (113) of the auxiliary sheath and the sheathhousing (114) of the introducer sheath, the auxiliary flushing channel(115, 115′, 115″) extends inside the connection region, particularlythrough a region of the wall of the sheath housing (113) of theauxiliary sheath that is located inside the introducer sheath (101). 10.The sheath assembly according to claim 9, characterized in that theintroducer sheath (101) and the auxiliary sheath (104) abut one anotherin an annular region as connecting partners, and in that in the annularregion, an annular or arcuate circumferential groove (116) extending inthe circumferential direction is provided in at least one of the twoconnecting partners, and in that, both in the sheath housing (114) ofthe introducer sheath and in the sheath housing (113) of the auxiliarysheath, a channel-like recess (117, 118) is provided, which connects theinner chamber of the respective sheath to the circumferential groove(116) in the connected state.
 11. The sheath assembly according to anyof the preceding claims, characterized in that a sterile tube (130) isconnected to the introducer sheath (101) in a fluid-tight connection,said tube forming a proximal extension of the introducer sheath (101)and encompassing at least parts of an auxiliary sheath (104), whereinthe sterile tube is connected in a fluid-tight connection to theauxiliary sheath (104).